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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_190_библиотеки_им_акад_М_И_Перельмана
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Laparoscopic Suturing — 67
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Figure 5.9. The needle andsutureare placed in the3-mm suture introducer. After the needle is passed through the tissue, the needle and
suture are brought out of the cannula and the suture is cut.
A
B
Figure 5.10. About 5 cm of the longest end of the suture is pushed
through the wire loop near the tapered end of the cannula. The inset
shows a close-up of this process.
C
Figure 5.11. The scored end of the cannula A is snapped off. The wire suture is pulled completely through B.
The scored end is discarded C.
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Figure 5.14. While grasping forceps hold the tissue being sutured, the
suture is inserted through the tissue.
Figure 5.12. The pretied slipknot is pushed off the conical end of the
cannula (inset).The excess suture is trimmed at theend of theslipknot.
The slipknotis pushed intothe trocar andonto the tissue tobe sutured.
25°
Figure 5.13. After the needle is positioned,it is grasped with the needle
holder.
Figure 5.15. The graspers hold the needle, and the needle holder
applies counterpressure on the tissue.
Figure 5.16. The needle is removed from the tissue. Enough suture is
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pulled through to form a knot, leaving a sufficient tail.
Laparoscopic Suturing — 69
Figure 5.17. The needle is grasped with a grasping forceps, and two
or three loops are made around the needle holder. The free end of the
suture isgrasped with the needleholder and brought inside theformed
loops (inset).
knots are applied over the suture, reversing the direction of the
sutures with each successive knot.
form a knot is pulled through, leaving a sufficient tail (Figure
5.16). The needle is grasped with a grasping forceps, and two
or three loops are made around the needle holder. The free end
of thesuture is graspedwith theneedle holder and brought inside
the formed loops (Figure 5.17), and using both grasping forceps
and the needleholder, the sutureistied over the tissue.Additional
REFERENCES
1. Weston PV. A new clinch knot. Obstet Gynecol 1991;78:144.
2. Clarke HC. Laparoscopy—new instruments for suturing and ligation. Fertil Steril 1972; 23:274.
3. Desai PJ, MoranME, Calvano CJ, Parelch AR. Running suture:the
ideal length facilitates this task. J Endourol 2000; 14:191–194.
6 INTRAPERITONEAL AND RETROPERITONEAL
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ANATOMY
Jyoti Yadav, M. Shoma Datta, Ceana Nezhat, Camran Nezhat, and Farr Nezhat
Sound surgical technique, whether during laparotomy or
laparoscopy, is based on accurate anatomic knowledge. Laparoscopic surgeons must adapt to the altered appearance of anatomy
due to the effects of pneumoperitoneum, Trendelenburg positioning, and traction from a uterine manipulator.There are inherent limitations of laparoscopy related to the fixed visual axis, loss
of depth of field, and magnification. Furthermore, laparoscopes
with different angles of view make orientation more challenging.
Because a three-dimensional field is projected to video
monitors as a two-dimensional image, it is imperative for the
endoscopic surgeon to understand that the anatomic structures
appearing superioron the monitor are actuallyanterior and those
inferior are posterior.
In this chapter, we describe some important anatomic relations that are critical during laparoscopic procedures.
SUPERFICIAL INTRAPERITONEAL ANATOMY
(LANDMARKS TO RETROPERITONEAL
STRUCTURES)
Superficial intraperitoneal landmarks within the pelvis alert the
operator to key anatomic structures in the retroperitoneal space
(Figure 6.1A–C).
The umbilicus is located at the level of L3–L4, although the
location varies with the patient’s weight, the presence of abdominal panniculus, and the position of the patient on the operating
table (supinevs. Trendelenburg). Theabdominal aorta bifurcates
at L4–L5 in 80% of cases.[1]
The parietal peritoneum over the anterior abdominal wall
is raised at five sites, representing the five umbilical folds. The
median umbilical fold, running from the dome of the bladder
to the umbilicus, covers the obliterated urachus. Lateral to the
urachus, on either side, are the medial umbilical folds, overlying the obliterated umbilical arteries. Just lateral to each medial
umbilical fold is the lateral umbilical ligament (fold), formed
by the peritoneum overlying the inferior epigastric vessels before
their entry into the rectus sheath as they course cephalad to join
the superior epigastric artery. In most cases, their location may
be visually confirmed through the laparoscope, avoiding injury
to them during the placement of accessory trocars.
On either side of the rectouterine pouch, the peritoneum
reflects over the uterosacral ligaments, forming the uterosacral
folds. Slightly lateral and superior to the uterosacral fold is often
another fold of peritoneum, the ureteric fold, which covers the
ureter.
Many additional key structures can be identified transperitoneally before any dissection. The internal iliac artery travels
parallel and just posterior to the ureter. The external iliac artery
is several centimeters anterior to it on the psoas muscle. The
external and internal iliac arteries may then be followed superiorly to find the bifurcation of the common iliac arteries at the
pelvic brim overlying the sacroiliac joint. This is an ideal location to identify the ureter traversing the point of bifurcation as
it enters the pelvis. The right common iliac artery may then be
followed superiorly to the bifurcation of the aorta, above the presacral space atapproximately thefourth lumbar vertebra. The left
common iliac artery is more difficult to identify because of the
overlying mesentery of the sigmoid colon. The left common iliac
vein is located just medial and inferior to the left common iliac
artery in the presacral space. At times it covers the entire space
between the common iliac arteries.
PELVIC BRIM
Multiple important structures enter the pelvic cavity at the pelvic
brim and canbeappreciatedlayerbylayer(Figure6.2A–D).Starting superficially from the peritoneal surface toward the sacroiliac
joint, the following structures are found in close proximity to
each other and can be recognized laparoscopically as superficial peritoneal landmarks: the peritoneum, the ovarian vessels
in the infundibulopelvic ligament, the ureter, the bifurcation of
the common iliac artery, and the common iliac vein. Dissecting
deeper layers, the medial edge of the psoas muscle, the obturator
nerve, and the parietal fascia overlying the capsule of the sacroiliac joint will be exposed. The lumbosacral trunk lies medial to
the obturator nerve.
PELVIC SIDEWALL
The pelvic sidewall is entered by openingthe peritoneal reflection
bordered by theround ligament anteriorly,the infundibulopelvic
ligament medially, and the external iliac artery laterally (Figures
6.3A–G and 6.4B). Based on avascular planes, there are three
surgical layers.
First Layer of the Pelvic Sidewall
Medially, the first layer is the parietal peritoneum with the ureter
attached to itin its own fascial sheath. The uretercan be retracted
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Right hypogastric
artery
Promontory
A
Right ureter
Sacral
Right common
iliac artery
B
Figure 6.1. (A) View of the right pelvic brim. (B) Deep inferior epigastric vessels run lateral to the umbilical ligament. (C) A laparoscopic view
of the pelvis. The inset shows the effect of the Trendelenburg position.
medially by incising this peritoneum, or it can be separated by
PELVIC LYMPH NODES
C
blunt or hydrodissection.
The external pelvic nodes arefound along the external iliacartery
and vein from the bifurcation of the common iliac vessels to
Second Layer of the Pelvic Side Wall
The second surgical layer consists of the internal iliac vessels and
their visceral anterior branches: uterine, superior vesical leading
to the obliterated umbilical, inferior vesical, vaginal, andthe middle rectal arteries.
the deep circumflex iliac veins caudally. The obturator nodes
are found in the obturator fossa, which is bordered medially by
the hypogastric artery; laterally by the external iliac vein, the
obturator internus muscle, and its fascia; and anteriorly by the
obturator nerve and vessels. The nodes along the hypogastric
vessels up to the bifurcation of the common iliac artery and vein
comprise the hypogastric group.
Third Layer of the Pelvic Side Wall
From anterior to posterior lie the (i) psoas muscle with the external iliac artery on its medial aspect, (ii) external iliac vein just
BASE OF THE BROAD LIGAMENT
medial and posterior to it, and (iii) external iliac vein beneath
the obturator internus muscle with the obturator nerve and
vessels coursing along its anterior border toward the obturator
canal.
The base of the broad ligament (Figures 6.4A,B) comprises the cardinal ligament, also known as the ligament of
Mackenrodt. Dissection of the pelvic sidewall will lead into this
72 — Jyoti Yadav, M. Shoma Datta, Ceana Nezhat, Camran Nezhat, and Farr Nezhat
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A
Left
round
ligament
Broad
ligament
Ovary
Ureter
Right common
iliac artery
Ureter
Common
iliac
artery
B
Right common
iliac vein
Right common
iliac artery
Infundibulopelvic
ligament
C
D
Figure 6.2. (A) The laparoscopic view of the pelvic brim before the incision. (B) A view of left broad ligament. (C) Right pelvic wall dissection
during pelvic lymphadenectomy. (D) The dissection of right pelvic sidewall is completed and the crossing of the ureter on common iliac vessels
at the pelvic brim is clearly seen.
region. It is importantto comprehendthat the internal iliacartery
continues into the superior vesical artery and then into the obliterated umbilical artery. Traction on the medial umbilical fold
will help identify the internal iliac artery, and the medial branch
passing superior to the ureter can then be identified as the uterine artery. The upper portion of the cardinal ligament is penetrated by the ureter as it travels into the tunnel of Wertheim just
beneath the uterine artery, 1 to 2 cm lateral to the isthmus of the
uterus, immediately lateral to the uterosacral ligament. This is
one of the most common sites of ureteric injury in gynecologic
procedures.
The base of the broad ligaments delineates two important
spaces: Anteriorly is the paravesical space and just posterior,
toward the sacrum, is the pararectal space. The extent of lateral
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dissection toward the pelvic sidewall and consequently excision
of the ligament of Mackenrodt determines the class of radical
hysterectomy.
AVASCULAR SPACES OF THE PELVIS
Three pairs of ligaments divide the pelvis into eight avascular
spaces (Figure 6.5A,B).
Prevesical (Retropubic) Space of Retzius
The space of Retzius, or the retropubic space, is a potential avascular space with vascular borders between the back of the pubic
bone and the anterior wall of the bladder (Figure 6.6).
The retropubic space is bounded anteriorly by the transversalis fascia, which inserts on the posterior surface of the pubic
symphysis. The urethra, the paraurethral (pubourethral) ligaments, and the urethrovesical junction (bladder neck) form the
floor of thisspace.The pubic symphysis and theadjacentsuperior
pubic rami with Cooper’s ligament represent the inferior limit.
Paravesical Space
Laterally, the retropubic space is contiguous with the paravesical spaces (Figure 6.7A,B), their point of separation being the
medial umbilical ligaments (obliterated umbilical arteries). The
paired paravesical space is bound laterally by the obturator internus muscle andthe obturator nerve,artery, and vein, justbeneath
the bony arcuate ridgeof the ileum.The posterior border (toward
the sacrum) is the endopelvic fascial sheath around the internal
iliac artery and vein and its anterior branches, as they course
toward the ischial spine. The pubocervical fascia forms the floor
of this lateral compartment as it inserts into the arcus tendineus
fasciae pelvis (fascial white line). The muscular white line (arcus
tendineus levator ani), which is the origin of the levator ani muscles, is justabove the levelofthe fascial white line. Accessory obturator arteries andveinsareoftenpresent and course from the inferior epigastric vessels and drape across the pectineal (Cooper’s)
ligament on their way to anastomose with the obturator vessels
in the obturator canal. The surgeon must always look for them,
such as in the case of a retropubic colposuspension, because they
are present in approximately 40% of patients.
A
Left obliterated
umbilical artery
Left external iliac
Left external iliac
Figure 6.3. (A) An incision is made in the left broad ligament lateral or parallel to the infundibulopelvic ligament to develop the paravesical space.
The round ligament can be divide either before or after this space is developed. This incision can be made by the scissors, the harmonic shear, or
by the CO
laser. (B) A view of the left obturator fossa. (Continued)
2
artery
vein
B
Left
Obturator
Fossa
Left obturator nerve
74 — Jyoti Yadav, M. Shoma Datta, Ceana Nezhat, Camran Nezhat, and Farr Nezhat
d
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Left external iliac
Left external iliac
artery
Obturator
nerve
External iliac
vein
vein
Left hypogastric artery
Left ureter
C
Obliterate
umbilical
artery
Superior
vesical
artery
External iliac
artery
D
Figure 6.3. (C) An anatomical view of the left pelvic brim. (D) Left pelvic sidewall retroperitoneal anatomy. (Continued)
Pararectal Space
The pararectal space is triangular, with the base of the cardinal
cul-de-sac peritoneum between the two uterosacral ligaments,
which lies superiorly.
ligament representing the anterior border (Figure 6.7C,D). The
medial border is the ureter and the lateral border is the internal
iliac artery. This space can be easily developed by bluntly dissecting posterior to the origin of the uterine artery and lateral to the
ureter.
Presacral (Retro-rectal) Space
The retro-rectal space is between the rectum anteriorly and the
sacrum posteriorly (Figure 6.10). This space is entered abdominally by dividing the mesentery of sigmoid colon or through
the pararectal spaces. Inferiorly this space terminates at the level
Vesicovaginal and Rectovaginal Spaces
The vesicovaginal space is a potential avascular space between
the anterior surface of the vagina and the posterior aspect of the
bladder,borderedlaterallybythe bladder pillars or thevesicouterine/vesicocervical ligaments (Figure 6.8A–C). Entry to this space
can be accomplished by incisingthe vesicouterine fold of peritoneum.
The rectovaginal space is bounded by the vagina anteriorly, the
rectum posteriorly, and the perineal body inferiorly and laterally
(Figure 6.9A–C). The space is entered by incising the posterior
of the levator muscle and laterally continues as the pararectal fossae. The middle sacral artery and a plexus of veins are
attached superficial to the anterior longitudinal ligament of the
sacrum. The endopelvic fascia in this space envelops the visceral
nerves of the superior hypogastric plexus and the lymphatic tissue. The lateral boundary of the presacral space is formed by
the common iliac artery, ureter, and inferior mesenteric artery
traversing through the mesentery of the sigmoid colonon the left
side.
Lateral and inferior dissection in the presacral space leads to
the structures entering the pelvis over the pelvic brim.
Uterine
artery
Right obturator
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nerve
Right obliterated
umbilical artery
Deep inferior
epigastric vein
Right obturator
artery
Right external
iliac vein
Right external
E
iliac artery
circumflex vein
Figure 6.3. (Continued) (E) Right pelvic sidewall retroperitoneal anatomy. (F) The course of deep inferior epigastric vein from its origin. (G)The
deep circumflex vein is identified during pelvic lymphadenectomy.
F
Left deep
G
76 — Jyoti Yadav, M. Shoma Datta, Ceana Nezhat, Camran Nezhat, and Farr Nezhat
r
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A
*
Left obliterated
umbilical artery
Left urete
Left uterine
artery
Left uterine
vein
B
Figure 6.4. (A) Right pelvic side-wall exposure. (B) To prevent injuries, the ureter must be identified before irreversible action is taken. Here is
one of the most vulnerable sites of ureteral injury and the anatomy of water under the bridge is clearly seen.
THE PARA-AORTIC REGION
muscle. A major concern on the left side is injury to the renal
The para-aortic region is theanatomic area from the renal vessels
down to thebifurcation of the common iliac arteries in the posterior abdominal retroperitoneum (Figure 6.11A-E). For practical
purposes, this region is divided into two areas.
The lower para-aortic area is bounded by the bifurcation of
the aorta up to the level of the inferior mesenteric artery superiorly, the psoas muscles laterally, and the bifurcation of the common iliacs inferiorly. Dissections for lymphatic tissue for uterine
or cervical cancer involve this area.
The infrarenal area (upper para-aortic area) extends from
the level of the inferior mesenteric artery up to the left renal vein.
Usually the ovarian arteries exit the anterior aspect ofthe aorta in
the midportion of this area. The right ovarian vein travels next to
the right ureter and empties into the vena cava. The left ovarian
vein travels with the left ureter but empties into the left renal
vein. These structures lie on the anterior surface of the psoas
vein and the lumbar veins and arteries arising from the posterior
aspect of the aorta and vena cava. The inferior extension of this
region is the “presacral” space.
The landmarks,which should be kept in mind for para-aortic
lymphadenectomies, from rightto left are the psoasmuscle; ovarian vessels; right ureter, medial to the psoas muscle and lateral to
the inferior vena cava; vena cava to the right lateral of the aorta;
and aorta and both common iliac arteries. Below the bifurcation
of the aorta superficially is the superior hypogastric nerve plexus
and the presacral nodes,and beneath them, the left common iliac
vein crossing from the left to the right. On the left side of the
aorta are the inferior mesenteric artery, the sigmoid colon, and
its mesentery. On a deeper plane are the lumbar veins and artery
medially and the left ureter laterally, which can be seen after left
lymphadenectomy. On the far left is the left psoas muscle (Figure
6.11C).
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